African-Americans and the Stigma of Mental Illness

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Research has shown that African-Americans are more likely to feel stigmatized by a diagnosis of mental illness than whites or Hispanics. Why is this and what can be done about it?

Join us as we speak to mental health experts and African-American community leaders about why there is such a heavy stigma attached to mental illness and how to change this perception. Also, find out which mental conditions are most common amongst African-Americans and what resources are available to help minorities find support and acceptance.

As always, our guests answer questions from the audience.

Announcer:
Welcome to this HealthTalk webcast. Before we begin, we remind you that the opinions expressed on this webcast are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.

Now here's your host, Patricia Murphy.

Patricia Murphy:
While African-Americans are only 12 percent of the U.S. population, they account for nearly 25 percent of our nation's mental healthcare needs, yet stigma in our society and the black community prevents many from getting help. Hello and welcome to this HealthTalk webcast, African-Americans and the Stigma of Mental Illness. I'm your host, Patricia Murphy.

Joining us is Dr. William B. Lawson, professor and chair of Howard University College of Medicine and Hospital Psychiatry Department and director of its Mood Research Program. Welcome to HealthTalk, Dr. Lawson.

Dr. William B. Lawson:
Thank you.

Patricia:
Dr. Lawson, mental illness is stigmatized in our society. How does the African-American community generally view mental illness?

Dr. Lawson:
It's actually a combination of thoughts that many folks have. One is we tend to be more tolerant of individuals who have some unusual or bizarre behavior. Many times when I see chronically mentally ill folks in the hospital, African-American families are much more likely to continue to visit them even when they have been ill for a long, long time. On the other hand, we are also much more likely to believe that the mentally ill can be dangerous or commit crimes or do other bad things. So in many ways many individuals are much more likely to avoid or stigmatize someone who is mentally ill versus someone who, say, has AIDS.

Patricia:
And what are the major barriers to mental healthcare for African-Americans within our predominantly white culture?

Dr. Lawson:
Some of it has to do with societal barriers, and the big one of course is cost. We make about 60 percent of the income of the general population, but we only have one-tenth of the family wealth because we have – just the aspects of slavery and so forth, we have just begun to accumulate wealth in our families. So we have very little disposable income or savings from past generations for a major crisis like mental illness, which can often cost as much as one's entire annual income in terms of direct cost.

The other has to do with the perceptions of African-Americans by the general community. We are seen as much less likely to become depressed. We are seen as much more likely to be, quote, crazy. We are much more likely to be hospitalized, much more likely to get involuntary treatment, much more likely to be treated in the emergency room, much less likely to be kept in the psychotherapy or even offered psychotherapy or newer treatments.

Among our community there are also a number of barriers in terms of how we perceive mental illness. We tend to see that as a character flaw, a problem with the individual rather than an illness or a disease. We tend not to be familiar with the symptoms of mental illness, and when we do seek treatment we are much less likely to seek treatment from a mental health physician. We will go to a friend, a family member, the clergy, or our primary care providers. And when offered treatment, we are much more likely to refuse medication treatment, although we will do some counseling.

Patricia:
Well, there is a lot in there, and we will certainly get to many of those questions and answer some of those questions as the program moves forward. But now I want to talk a little bit about the Listening Project. It was sponsored by the National Alliance for Mental Illness. Now, this is something you participated in and was a dialogue between African-American psychiatrists and NAMI to find out ways to better reach out to the black community. One recommendation was that NAMI leadership needed to understand institutional racism. Tell us why this is so important.

Dr. Lawson:
Part of it has to do with the fact that, again, African-Americans are less likely to be volunteers for a variety of reasons including income. And so in the past NAMI simply hasn't had many African-American members, so many of the individuals, though well meaning, are simply not appreciative of the fact that there are structural barriers that are independent of people's individual attitudes that affect folks' availability of treatment and also of care. The old concept of institutional racism reflects the fact that we still have many institutional barriers that de-emphasize or stigmatize those people of color that make treatment and other support very often unattainable.

Patricia:
And how would it improve outreach to the black community?

Dr. Lawson:
I think a major part is that we often get stuck with the whole thing about, “Is there racism?” Are people's attitudes important? And many whites have difficulty, feel uncomfortable with taking that first step because they themselves don't see themselves as having negative attitudes towards African-Americans. But when we look at such issues as, who do you hang out with, who your friends are, what are your relationships like?

When [people] are presented with someone who is African-American who is showing unusual behaviors, it makes a great step to look at folks with compassion rather than looking at them as if they are to be punished. African-Americans are much more likely, when showing the same behavior as whites, to end up in the correctional system rather than to get mental health treatment. And that's much more of an institutional factor and persisting attitudinal belief than it is about a single individual's attitude.

Patricia:
Interesting. There are barriers to mental healthcare within the African-American community itself – what are they?

Dr. Lawson:
Well, the big one of course is income, but the other one is also the stigma attached towards mental health providers. There is much less diversity of African-American providers, less than three percent of psychiatrists for example. And very often the exposure to the mental health system is one of hostility and involuntary – such factors as involuntary commitment than it is of a place of support.

And then there are historical thoughts about delivery of mental health services that relate to the way in which psychology has implemented social policy in the past related to the African-American community. For instance, there was some psychological testing that was used to justify the whole segregated school system that we had.

Patricia:
Many African-American artists and writers and celebrities are, quote, coming out of the closet with their experiences with mental illness. Who are they? And what impact is this having on the community?

Dr. Lawson:
There are a number of artists, and I might add that I think it's pretty clear that mood disorders seem to be over-represented among people who are creative – not that there is something wrong with creative people, just that the argument you have to have a mood disorder to be creative tends to be a little bit more common.

Some individuals like Terry Williams, publicist, social worker, has written an excellent book, “Black Pain,” that attempts to address this issue. Mike Tyson, the boxer, has suffered with depression and I think probably bipolar disorder for years, and also a number of the rap stars. Jimi Hendrix suffered from depression for years as well.

Patricia:
And how do you suggest African-Americans deal with the stigma of mental illness?

Dr. Lawson:
Part of it is that we often go along with the stigma in our daily lives by avoiding situations that are stigmatizing, by putting it in the closet. There are still individuals who keep the mentally ill individual locked behind closed doors. We have many individuals who cannot admit it to themselves, who hide the pain in other ways, by showing violent behavior or doing harm to themselves. And of course many of us tend to seek self-medication, either through drug abuse or alcohol.

Patricia:
Right, and that certainly crosses all race lines.

The Surgeon General reports that only two percent of psychiatrists, two percent of psychologists, and four percent of social workers in the United States are African-American. How do those cultural differences between the black community and mental health professionals of European descent affect diagnosis or misdiagnosis?

Dr. Lawson:
I think it's pretty clear that misdiagnosis and underdiagnosis is very common, especially among African-Americans. A big factor is the lack of appreciation of cultural factors and appreciation of understanding the community in which we live by the providers.
For example, we often, when we are depressed, do not complain about being sad or guilty. We often go in and complain about physical complaints. “I have a pain in my body, I'm falling out, I'm tired, I'm just done.” And sometimes in [times] of extreme stress, some of our folks will disassociate, and that can be interpreted as psychosis. Many times we use some slang terms that many in the white community might not be thinking about [and so] will say they have a thought disorder. But we have people who have problems like post-traumatic stress disorder, when they talk about flashbacks, they will say the guy is psychotic. People who have depression, when they talk about not having any energy, they say they must have a physical problem. We have people with bipolar disorder, when they talk about their feelings, we don't often say we feel euphoric or great, we feel irritable. We say they are criminals or they are violent people.

Patricia:
I've read that African-Americans are four times more likely to be diagnosed with schizophrenia than whites. Why is that?

Dr. Lawson:
That's actually an improvement. When I was in school, it was ten times more likely. But one of the reasons, again the problem of unfamiliarity with the symptoms and the lack of appreciation of the role in which culture plays in which the symptoms present themselves. A good part of it has to do with the fact that in schizophrenia part of the disorder is an inability to relate to others, and there is already cultural distance. That cultural distance may be interpreted as reflective of the schizophrenic process.

Also, many African-Americans are simply not willing to disclose to people they don't know, and especially to mental health providers. Some of them call it a healthy paranoia. And of course unfamiliarity with slang terms, unfamiliarity with dissociative experiences can often be treated as psychotic behavior.

Patricia:
So do African-Americans need black therapists?

Dr. Lawson:
Well, that would be wonderful if that could happen, but there are just not enough therapists to go around. I think what we need to do is try to emphasize the importance of teaching of culture and its impact so that other therapists can learn and provide services to African-Americans as well as others.

Patricia:
Why do you suspect that there are so few black therapists?

Dr. Lawson:
Part of it has to do again with the stigma. Part of it has to do with the general problem of getting higher education, and part of it has to do with the lack of compensation that many folks have, and the absence of role models.

Patricia:
Do you see that changing any time soon?

Dr. Lawson:
I think it is. The demand by many individuals to seek therapy, recognition that mental disorders are treatable, it is pushing, I think, more folks to consider therapy as a career than ever before. Many of my patients I am seeing are demanding to have African-American therapists, and I think that message is heard from their family members as well as young people who are trying to think of career options.

Patricia:
The Surgeon General also reported risk factors for mental illness that are prevalent in the African-American community. Tell us about those.

Dr. Lawson:
There is has been a huge debate going on about whether or not poverty in itself is a risk factor for mental illness. What we suspect are things like head injury, which we are actively doing research on right now, as well as lifestyle circumstances may be triggers. Again, environment doesn't always cause mental illness, but it can precipitate it in those who are at risk. Substance abuse is a well-known, important trigger. Trying even marijuana is a high risk factor for individuals that are at risk. Schizophrenia has been associated with a number of problems such as prenatal conditions which may be not optimal in the African-American community.

But one mental disorder is clearly related to the environment, and that is post-traumatic stress disorder (PTSD). What we find is that many folks in the inner city areas, because of sometimes gang wars, gun violence, high frequency of child abuse and other issues related to low income, like challenged economic status, limited opportunities, results of single-parent families, can increase the likelihood of this disorder.

Patricia:
Are there efforts being made to reach out to folks who live in inner cities who may be suffering from PTSD?

Dr. Lawson:
There have been some. Part of the problem has been that, interestingly enough, many of the public hearing the name [PTSD], they often don't think about it in inner city areas. It's still very much recognized as an issue involved with the military.

But what we now know is that people who have had PTSD before they got in the military are much more likely to suffer it after they have been exposed to a traumatic situation in the military. But again, the way in which it is manifested is, for instance the anthrax scare that occurred among the federal courts in the district, there was a lot of emphasis that was put on getting the judges and the congress taken care of, but there was very little attention paid to the post office workers who had to handle the material and who many of them later developed PTSD.

Or 9/11 – a lot of emphasis was put on the accountants and other professionals that were in the building, but not very much about the people that provided the custodial care and maintenance of those buildings or those who lived in the immediate community around.

Patricia:
Does the church add to the stigma of mental illness in the African-American community?

Dr. Lawson:
The church can both add to it as well as be a wonderful support. Many of our ministers are in fact reaching out to the mentally ill and recognizing them as ill and providing the kind of support they would to anyone else who has a problem or even those with physical illness. Many ministers are getting training in counseling and in those kinds of psychotherapy to supplement the spiritual approach.

On the other hand, there are many others who still see mental illness as a character weakness, a lack of faith, an unwillingness to fully commit themselves to a spiritual experience. So part of what we have to do is begin to educate the churches, and where we have done this the results have been very, very effective in terms of being an occasion to provide experiences for the community, bringing more people out who are willing to talk about the problems they have, and often providing a link between the minister, the therapist and other mental health providers.

Patricia:
That church could play an active role in bringing people to a mental health program if they chose to get involved in that.

Dr. Lawson:
Absolutely. And the church could play a very important preventative role as well, because many churches sit empty on days other than Sunday, and they can be a place where community [groups] agree to come together to address a number of community issues, including the support they need, then they help prevent mental problems down the road.

Patricia:
Dr. Lawson, many African-Americans go to the emergency room for mental healthcare. Why is this a problem?

Dr. Lawson:
Because many mental disorders either can be prevented or can be effectively treated if they have ongoing treatment. I don't know of any mental disorders that resolve to a one-step intervention. That's very, very rare. So what happens is that without early, ongoing treatment, mental disorders may persist and progressively get worse. Emergency rooms are important. They play an important role, but it must be in the context of an overall system of providing ongoing care.

Patricia:
Now, could emergency room doctors do to a better job of connecting people who need mental healthcare with the services they need?

Dr. Lawson:
Emergency rooms, primary care physicians, OB/GYN – we are recognizing that there are a number of providers that can play an important role in terms of the process. The importance of postpartum depression is an important issue, maybe more common in the African-American community, and obstetrics and gynecology is very important in that role. We find that people in primary care clinics are probably the first line and treat more mental disorders than any others. And of course when folks are under stress and have not had treatment, the first place they go to is the emergency room. The emergency room can be an important link in making sure that folks then get ongoing, effective treatment.

Patricia:
One major concern about the lack of mental healthcare is that African-American children are less likely to get treatment. How does this impact the black community in the short term and the long term?

Dr. Lawson:
What we know is that what happens early in life has a tremendous impact on what happens later in life in terms of a successful life, in terms of completing school, in terms of getting a strong education, in terms of getting a job, in terms of avoiding the criminal justice system, in terms of being able to have an effective marriage, and subsequently in terms of child rearing. Most mental disorders strike in the early or late teens. Some strike in childhood. And if they are not recognized as mental disorders, many times kids are criminalized or may even be ejected from the system and as a result never realize the potential to develop what they have.

Patricia:
Do schools play a role in diagnosing kids with mental illness?

Dr. Lawson:
They can play a very important role. It's interesting – we are getting better – but historically while schools often have a health nurse and sometimes have a speech therapist, they often would not have a psychologist or a child psychiatrist or someone who is trained to recognize mental disorders. Although it is getting better. Working with teachers, working with the school nurse, we find that we can create a system in which students who have mental problems can be easily recognized and referred for treatment.

It is important to recognize that at least for African-Americans the young men are at the greatest risk for suicide, and we suspect that much of this suicidal behavior and perhaps some homicidal behavior is related to an absence of mental health services.

Patricia:
Could the school's role in diagnosing kids with mental illness be harmful to children?

Dr. Lawson:
It can be if it is done in a way that is stigmatizing, without providing positive treatment. It is now recognized for instance that early intervention in terms of post-traumatic stress disorder, if not done by trained professionals in the appropriate way, can actually make it worse, for example. Also, there have been cases of students being overdiagnosed with such problems as attention deficit disorder while other disorders such as bipolar disorders may be completely missed.

Many times it is easy for schools to provide medication only. Medication can play a very, very important role, but it should be in the context of providing supportive therapy involving the family as well as the student.

Patricia:
And you touched very briefly on this a few moments ago, but there is a myth that black people don't commit suicide. And in fact the suicide rate among black men between the ages of 15 and 24 has been climbing at an alarming rate over the last 20 years. Is this the only age group that is affected by this?

Dr. Lawson:
No. All age groups are affected. It is just that relatively speaking what we find is that, at least in African-American men, that it is the young men that show the highest rate. There is still a debate going on about whether or not this is really a true increase or are we just recognizing it as suicide because we used to believe that black people didn't commit suicide until we were forced to recognize it as such. But it can happen in all groups. Right now, historically, African-American elderly men didn't commit suicide as [often as] their white and Asian counterparts. That's beginning to change. The rates are beginning to increase in that population as well.

Patricia:
What are the factors in the suicides? Why are these young and older men killing themselves?

Dr. Lawson:
I think a good part of it is a failure to recognize that they have disorders such as depression, perhaps bipolar disorder or even untreated ADHD or schizophrenia or post-traumatic stress disorder. A large part of it is knowing when they are under extreme stress or difficulty. Society puts high expectations on the achievement of men, and yet they find themselves not being able to keep up with their counterparts.

And another is the conflict between the belief that somehow racism and all of its structures have been renewed and the reality for many African-American men of what we call “micro-insults,” very subtle, pervasive experiences that are racist in nature.

Patricia:
So when all this manifests, it's quite profound.

Dr. Lawson:
Right.

Patricia:
When we spoke earlier, you mentioned that up to 50 percent of the people in the criminal justice system have mental illness, and 70 percent of that population is black. As a culture are we substituting prisons for mental healthcare facilities?

Dr. Lawson:
That's a good question. Some are calling the mental health system in the correctional system the new asylums. Places like the Chicago County, the Cook County jail, the LA County jail are now the biggest mental health providers in our country. So at a time when we are doing more to deinstitutionalize, spending less money in terms of inpatient services, at the same time paradoxically we are having to put substantial amounts of money in terms of the correctional system. And I am not sure that we are getting the bang for our buck that we want. If we were able to provide mental health services to these individuals before they were criminalized, society would realize substantial savings. And once one goes into the criminal justice system, it makes rehabilitation and return to normal society more difficult with a lack of opportunities to learn basic skills of working and becoming employed, getting an education and other factors that are necessary for an effective life.

Patricia:
So do inmates get mental healthcare in the prison system?

Dr. Lawson:
They, about maybe 80 percent of the time, don't get anything at all other than perhaps acute emergency care. The numbers in terms of how many people are mentally ill in prisons are usually the result of, when we go into prisons, using structured interviews to interview folks and then diagnosing, not because those people are being recognized as mentally ill and seeking treatment. So there is a huge service gap in terms of the correctional system. And it's a system that's not really designed to provide ongoing, comprehensive mental health services. Certain mental disorders are probably the biggest cause of the incredibly high, 50 to 90 percent, recidivism rate that we find in many of our correctional centers.

Patricia:
Is that issue of mental healthcare and prison being addressed in the mental health community or within the federal government?

Dr. Lawson:
It's being addressed, but I think much more has to be done. It's certainly not getting the resources or the interest that would reflect this incredible cost to society as well as to the individuals involved. But the National Alliance of the Mentally Ill, the Bipolar Depressive Support Alliance as well as some universities are making active efforts to work with the correctional system to provide mental health services. But again, these are mostly demonstration programs. They do not reflect a more comprehensive program.

There is more being done in terms of substance abuse, recognition that treating the people in prisons reduces recidivism. It is already convincing to folks in terms of the importance of providing substance abuse treatment. But the treatment of other mental disorders is not moving as quickly. There have been – just as with substance abuse where they have set up drug courts to intervene early enough so that alternatives to prison can be found – there are also mental health courts as well so that individuals who are being adjudicated may be recognized and provided appropriate mental health treatment.

Patricia:
It sounds like from what you are saying if we could get to people a lot earlier, we would have less people in the justice system in the first place.

Dr. Lawson:
There is a lot of evidence that would support that that would be a very, very important and effective intervention and would reduce costs for all systems.

Patricia:
Right, and I guess it would go across all lines, if you could get somebody involved in a support network of mental healthcare that would just follow them throughout their life.

Dr. Lawson:
Absolutely. But again the problem of stigma, the problem of what's the best way to allocate our resources, the double stigma of being in the correctional system and being mentally ill is a tremendous barrier to overcome.

Patricia:
Much has been written recently about the depression that African-American men suffer, but we don't hear as much about mental illness around black women. Why is that? Are African-American women actually less likely to have mental illness?

Dr. Lawson:
African-American women are more likely to be depressed and at greater risk for developing post-traumatic stress disorder, but the suicide rate is substantially lower, and many women simply do not act out in a way that makes it as dramatic to the larger society, so they don't get the attention that would be gotten if someone was involved in, say, criminal activity.

Also many African-American working women have gotten some support from church and from work and from supporting each other so that some of the consequences of mental disorder may be lessened. But at the same time many do suffer in silence. There is increasing evidence that having an unrecognized mental disorder has consequences not only for the person but also makes it less likely that that person will have a meaningful relationship later in life and also has direct consequences on the child. Mothers who are depressed have children who have, not only depression, but also correctional problems, difficulties at school, and a whole host of other problems, especially when they are not adequately treated.

Patricia:
Suppose an African-American wants to get help for mental illness. How should they get started? Where should they start to look for help?

Dr. Lawson:
Actually there are a number of opportunities to find. Depending on which state they are in and the jurisdiction, there are often state departments of mental health as well as local community, county mental health agencies for those who do not have the direct funds. Those who have the funds, there are a number of providers that are now available and could be reached through provider networking organizations.

We are involved with a group called The Black Psychiatrists of America, which is a Web site and which can help link individuals who are seeking African-American providers. Similarly, the Association of Black Psychologists as well as the Association of Black Social Workers can serve as means of getting people of color as their providers, recognizing that still even with these organizations there is a shortage of providers, and so you may want to seek culturally aware and culturally sensitive folks that may not be African-American. But again, we can go to an African-American provider who may themselves have a full schedule who can help refer you to someone that they feel may be culturally sensitive.

We also have historically black medical schools that are very much actively involved in state-of-the-art treatment and especially for individuals who have very complicated problems available to provide services. Of course, we have Howard University Medical School in Washington, D.C., our Department of Psychiatry and Behavioral Sciences; the Meharry Medical College in Nashville, Tennessee; the Morehouse School of Medicine in Atlanta; and the Charles Drew Medical Center in Los Angeles. These can also be starting points for finding other similar providers in other places. The departments tend to maintain a strong link to the providers they enlist in the communities throughout the country.

Patricia:
Now, after all of that, after finding a therapist and going through all of the rigamarole of getting a therapist, studies show that up to 40 percent of African-Americans don't return to therapy after the first visit.

Dr. Lawson:
Part of it has to do with the culture of what do you mean by being mentally ill, and part of it has to be a general problem. Mental disorders tend to be chronic, and in general folks don't usually deal with treatment after the first visit. The problem that we see in getting ongoing treatment with mental disorders is about the same problem that we see in getting ongoing treatment for hypertension, for diabetes, for a number of chronic disorders.

In addition we are also taught that if we feel better, don't come back. And many folks get what we call a flight to health – walk in, have a very good relationship with the therapist, and never come back again because they feel as if they have resolved the problem.

Patricia:
We talked a little bit about being culturally aware in therapy. When an African-American decides to get treatment, what else do they need to look for in a therapist?

Dr. Lawson:
What we have found is that sometimes there is not a good match between the therapist and the individual. Many times the individuals will blame themselves, that they may not have been a good patient or a good subject. Sometimes the individual may blame the therapist and say they are not treating her right or they are making it more stressful. But the question that the person should ask is, at the beginning, let the therapist know what the expectations are. Some types of therapy require that a person get a little bit more anxiety later on. Find out how long before they expect to see some results. What we find is that many folks do not like it when the therapist disrespects or does not listen to them. That is important. They should consider another therapist at those times. And a key point is if the therapist is not knowledgeable about the community, are they willing to learn and listen as they interact with the person?

Patricia:
Historically, medication has also been a problem for African- Americans. Tell us more about that.

Dr. Lawson:
It probably has to do with the fact that many folks have this fear that medication is going to change their core being, who they are. They do not like the idea of getting chemicals or do not feel a link between what's happening in a chemical and what's happening in their spirit, their personality, their behavior. And there is the stigma that is attached with the way that new treatments and drugs are developed through research, and the African-American community historically is very, very suspicious of research, especially after the Tuskegee syphilis study and other unfortunate episodes in which African-American patients were taken advantage of or could not and did not have access to the full rights of treatment that they should have.

Patricia:
When an African-American is prescribed medication, how can they be sure they are getting the proper dose and that it is helping them?

Dr. Lawson:
It's a very good question. One of course is to talk to the therapist and make sure the therapist is open about the side effect profiles and such. It's important because what we know is that African-Americans are not included in many of the clinical trials in sufficient numbers to really understand some of the side effects or rapidity of action that you may want to expect to see in African-Americans. So the literature may not be accurate in terms of the right dose that the person [requires].

On the other hand, like this therapist, won't she recognize that and be able to work with the patient to be able to find an effective dose that has minimal side effects?

Patricia:
And if medications don't work or side effects aren't manageable, what should people do?

Dr. Lawson:
The ideal treatment is to combine medication with psychotherapy. In some people, the psychotherapy works a lot. In some people the medication works with minimal effects of psychotherapy. So combining the two often gets the best outcome. And that way we find that if for instance medication doesn't work, the person can still continue with what we know as evidence-based psychotherapy.

Patricia:
And this is so problematic, what would you say to people who take their medications, feel better, then stop taking it?

Dr. Lawson:
That again comes from our society with instant gratification – take a pill, you got pneumonia, you take your penicillin shot, you go home, the pneumonia is gone. But for many psychotropic medications, a better analogy would be the medications you might take to treat hypertension or diabetes, where you are taking a medication to prevent a recurrence of the illness because again many psychiatric disorders do tend to be chronic disorders.

Patricia:
We have so many e-mail questions, so let's gets started. An anonymous e-mail comes in, and the question is, “Why do black people so often attribute mental illness to negative spiritual experiences?”

Dr. Lawson:
Part of it has to do with our background, some of our African heritage, the fact that when many of us were raised in an environment in which less emphasis is put on, quote, “scientific explanations” and more emphasis is put on relationships and spiritual events. So many of us are very much aware of the role of relationships and spirit, and the idea of a mental illness being a disease, a biological mechanism, scientific evidence, all of that is still relatively new. Many of the treatments and observations were only made in the last ten years.

Patricia:
And other e-mail comes in. “What's being done with regard to police brutality perpetrated on people with bipolar disorder?”

Dr. Lawson:
We have been involved with trying to educate the police departments, and that seems to be the most effective way. That is, to begin to work with the police department, let them know there are alternatives, and to help them to recognize when someone is mentally ill. The National Alliance of Mental Illness as well as the Mental Health Association have developed videotapes that have been used to train police. You can take an investigatory way, but again what we are doing is talking about changing the culture of whole police departments, and using an educational way is the best way.

Patricia:
An e-mailer from Jackson, Mississippi writes in, “I am a 37-year-old African-American. My bipolar went undiagnosed for almost 13 years. Now my family treats me like I am stupid. How do I get them to understand this condition?”

Dr. Lawson:
There are now a number of Web sites and books that help to identify this condition. The Depression, Bipolar Support Alliance has a Web site that has information. We are now coming up with more that we are trying to put out in doctors' waiting rooms so folks can be made aware of this. A large part of this has do with beginning to educate folks, getting the materials and educating them that this is in fact an illness, not an illness that is necessarily like Alzheimer's that causes dementia, but an illness that can temporarily impair a person, but with proper treatment that impairment can be reversed.

And what he describes is a very important issue, and that is in general bipolar disorder is often only diagnosed eight to ten years after it first manifests itself. As a result many individuals go through long periods of their lives not understanding what's going on, suffering, knowing something is wrong, but simply not having a name for it.

Patricia:
Now, it sounds like that person is also in treatment. Would it help to have their practitioner reach out to the family?

Dr. Lawson:
That's something we need to work more on. Many of us were taught to try to work primarily with the individual. What we are beginning to recognize now is that especially for bipolar disorders, you have got to have the whole family in it to recognize what it is. Many times we have missed the diagnosis because we haven't involved other people who can give a different perspective of what a person sees. And then what we are finding is that having family members working with the individuals can be a very, very effective way of dealing with the problems with medication and dealing with having the person to appreciate that when they have done something that is unacceptable, rather than having them become severely depressed, that they do have the support of family members who can work with them to keep that from happening in the future.

Patricia:
An e-mailer from Stone Mountain, Georgia writes, “Why is there such apathy among some civil rights organizations for the incarcerated mentally ill?”

Dr. Lawson:
Because of the stigma that's around incarceration and also because of lack of resources. Right now many civil rights organizations are challenged. The correctional system is a very, very, very, very big fish to fry. And again they want to look at that which can help for the organization get the best bang for their buck. Dealing with the two stigmatized problems of the mentally ill in the correctional system simply is not going to cause a program to end up in Time magazine with a lot of accolades.

Patricia:
An e-mail from San Antonio, Texas – the listener writes, “I believe that there is a high association between cocaine abuse and bipolar disorder and that the two are very nearly the same. Why don't clinicians address this concept and treat these conditions accordingly?”

Dr. Lawson:
They should be. It has been long known that bipolar disorder is a major risk factor for substance abuse. Sixty percent of people with bipolar I end up with substance abuse and half with bipolar II end up with alcohol associated disorder. So there is a strong association. Whether or not there is an underlying biological, genetic, environmental factor that contributes to this, we don't know, but we do know that there is a much greater association than most other mental disorders. And it's been well documented that the best treatment is to treat them simultaneously. However, our system of provider services often separate mental disorders from substance abuse, and so we often have to figure out a way to get both treatments because when we do it sequentially, we simply do not get the best results.

Patricia:
And the idea of dual diagnosis is fairly recent.

Dr. Lawson:
The concept is recent. The reality is not. Dual diagnosis has been around from the time man first discovered that fermented material could produce alcohol. But unfortunately in our culture, we like to develop separate institutions and systems. It's very often the case that substance abuse and alcohol is at one location, one provider services, one group of training, and the mental illness is at another.

Patricia:
We have an e-mail from Puerto Rico now. “I would like to know what the privacy rights are for bipolar patients on the job.”

Dr. Lawson:
Again, it depends on the state, but usually the person has no obligation to inform the boss or the employment agency that they have a disorder, but the reality is that because of the stigma, sometimes folks can be terminated. There are protections offered by the Americans with Disabilities Act. But again there are certain professions, such as the legal profession, for instance, in which disclosure to the bar is mandatory.

Patricia:
Longview, Washington writes in with a question, “Why are therapists not trained to understand the cultural and economic factors which lead to single parents raising black children so they did not condemn or criticize or undervalue many single parents who are contributing and raising children the best way they know how? At what point do therapists realize single parent black households may now be the norm, and not the exception?”

Dr. Lawson:
I think the fact is that there are years and years of research showing that the nuclear family or even perhaps the extended family is the best way to raise children. And there is only recent data showing that that may not be true – single parents can effectively raise children. But still there is just a whole host of [evidence showing] otherwise. And I might add the African-American community has more single parent men raising families than any other ethnic community.

But the belief is that they have lower income, they often don't have power, it runs into a conflict in terms of how to be successful at work – all contribute to this feeling. And many therapists themselves see that the short [answer] is simple – they should somehow get married and everything will be hunky-dory. The reality is that we are finding many, many more individuals are single, have offspring, and given the right support, can have as effective an outcome as those that are in a couple or an extended family. It helps if the single parent by the way is within the context of an extended family, because that can provide the support that you would normally see from the nuclear family.

Patricia:
A listener from Austin, Texas writes in, “I am a true believer that a tragic event in our lives can cause us to become bipolar.”

What is you opinion on that, Dr. Lawson?

Dr. Lawson:
I think it's clear that a tremendous event can be a trigger for underlying bipolar disorder, but there are many people who develop bipolar disorder and nothing has happened. They are living perfectly nice, comfortable lives, and then bang, the disorder is very much there. So like any other thing, like any other disorder, clearly having a traumatic experience greatly increases the chance of bipolar disorder, but it is not the only way that one can get it.

Patricia:
Does gangster rap with its message of suicide, murder, and drug trafficking contribute to the increasing suicide rate and the rate of violent crime among African-American men ages 15 to 24?

Dr. Lawson:
It's been demonstrated that knowledge of suicide, exposure to suicide, especially related to someone that's close to the individual's own age, and if they have access to guns or other easy way to commit suicide, the rate goes up. But the real effect of gangster rap and others is not so much that they contribute to suicide, but they are blunting the emotional feelings that one feels about violence in general, thus making violent behavior more permissive.

Patricia:
A listener from Port Jefferson Station, New York writes in, “At 53, my otherwise healthy African-American brother, who had always been very health conscious was diagnosed with depression. At 55 he was diagnosed with bipolar disorder. This occurred almost immediately after a period of extreme stress. He is very isolated in a home where his wife and teenage daughter don't understand his plight. His doctor has prescribed medication that is documented as being very risky. What steps can I take to be sure that he has not been misdiagnosed? And if the diagnosis is correct, how can I be assured that the prescribed medication is not placing him at greater risk?”

Dr. Lawson:
Seeing someone who may not be adequately treated for a mental disorder really wants us to make the best intervention possible. However, we must be careful and recognize that the individual has certain privacy rights. And so you must work with the individual to see if they want you to make that intervention and at the same time show you come from a place of concern and care. It's important to understand what's happening to be able to look and see if in fact some of the events are true. For instance, if the person has an intractable mental disorder, it may be that the physician may have to decide that the benefit-risk factor for certain medications are required, and he may want to use some that are more risky than others.

Again, I think we are beginning to appreciate much more that mental disorders can be devastating for individuals, and we want to do what we can to make them have a good outcome. Bipolar disorder, it used to be thought, did not have a bad outcome, but we are now recognizing that without treatment, it can be as severe as schizophrenia. Again the privacy issues as well as making sure that you don't [defeat] yourself by approaching the family aggressively and then having them not want you to have anything to do with them. This is very crucial. You may want to work with a support organization, like the DBSA or the National Alliance for the Mentally Ill to see the best way to intervene in that circumstance.

Patricia:
An e-mailer from Pensacola, Florida writes in, “How do we get people to accept that they have mental illness?”

Dr. Lawson:
With difficulty – it has a two-edged sword. Mental illness, especially with a prior mental illness, that in itself can be a potential risk factor for suicide. Part of it is to help the person recognize that a mental disorder is a brain disease, that it has many elements like any physical disorder. But the good news is that 70 to 90 percent of the time, we can treat mental disorders effectively so that the person can return to the community and perhaps even to constructive work.

Patricia:
An e-mailer from Wisconsin writes in, “How can you get your loved one with mental illness to keep taking their medication? Either they say they feel fine, or just don't take it, or they tell you they are seeing or hearing things and they won't take them. What can I do?”

Dr. Lawson:
Excellent question. Very, very good question. And also one of the most important questions we have. We have treatments that can be effective, but they don't work if they are sitting in the bottle or sitting on a table and not within the individual. Part of it is establishing trust with the individual, letting them know that you have their best interest at heart. Part of it is what we call psycho-education, making sure the person understands the medication's benefits versus the risks and side effects.

And part of it also is to help the other individuals to know the consequence of what happens when they are mentally ill. Many people simply don't know the impact of what is going on. They just know they may have some internal problems, but the effects on others around them may be quite devastating.

Patricia:
We are almost out of time, but before we go, Doctor, briefly can you give our listeners the first three steps an African-American should take to get help for mental illness?

Dr. Lawson:
Step one is to become aware and read about mental disorders. Watch the news, try to get accurate information about mental disorders from your provider, from other mental health specialists.

Step two is to be able to recognize when you have, when there is mental disorder present in friends or family. It may not be a mental disorder. It may be an idiosyncratic behavior. A person may be just plain bad. But keep in mind some of what's going on in your own life and others' that's causing ongoing problems and stress and not being resolved is maybe a mental disorder.

And step three is if it is a mental disorder and you are receiving treatment, work with the provider to see that treatment is ongoing.

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